Retroperitoneal and abdominal bleeding in anticoagulated COVID-19 hospitalized patients: Case series and brief literature review

Table 1 Case characteristics from the current case series

Characteristic	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5	Patient 6
Age in yr	63	51	74	86	80	92
Sex	Female	Female	Male	Female	Female	Female
Comorbidities	AH, Asthma	AH, renal transplant, CKD, history of abdominal tumor surgery	AH, IHD, Tonsil carcinoma (status post radiation)	AH, COPD, CKD	AH, ischemic stroke	AH
Chronic anticoagulant/antiplatelet use	ASA	No	No	ASA	ASA	ASA
Clinical presentationat admission	Fever, asthenia, myalgia	Asthenia, dyspnea, cough	Fever, asthenia, loss ofappetite	Fever, asthenia, dyspnea	Fever, asthenia, diarrhea	Fever, asthenia, dyspnea, cough
Duration of illness before admission in days	5	20	11	7	7	7
SpO2 at admission, %	92	94	94	78	87	97
Time from admission to bleeding in days	9	2	5	10	10	6
Type of bleed	Intraperitoneal	RSH, Extra-peritoneal	SRH	RSH	SRH	RSH
Signs and symptoms of bleed	Abdominal pain	Leg edema, asthenia, low hemoglobin	Abdominal pain	Abdominal pain, hypotension, abdominal guarding	Abdominal Pain (lateral)	Low hemoglobin, abdominal swelling
Hemodynamic instability	No	No	No	Yes	No	No
Maximum O2 therapy prior to bleed	15 L, mask	3-4 L, mask	9 L, mask	4 L, mask	7 L, nasal	OTI
Pulmonary changes	Moderate	Severe	Mild	Mild	Moderate	Moderate
Length of hospitalization (days)	20	15	20	11	25	10
Anticoagulation (prophylactic)	LMWH 4000 IU, BID	No	LMWH 4000 IU, BID	LMWH 4000 IU, BID	No	LMWH 4000 IU, BID
Anticoagulation (therapeutic)	No	LMWH 4000 IU, BID	No	No	LMWH 6000 IU, BID	No
Antiplatelet therapy	ASA	No	ASA	ASA	No	No
Steroids	Methyl-prednisolone	Methyl-prednisolone	Dexa-methasone	Methyl-prednisolone	Methyl-prednisolone	Methyl-prednisolone
Bioproduct units (pRBC/FFP)	2/3	4/4	3/2	2/2	No	No
Surgery	No	Yes	No	No	Yes	No
Outcome	Discharged	Discharged	Discharged	Died	Discharged	Died

AH: Arterial hypertension; IHD: Ischemic heart disease; AF: Atrial fibrillation; CKD: Chronic kidney disease; COPD: Chronic obstructive pulmonary disease; PE: Pulmonary embolism; PM: Pacemaker; ASA: Acetylsalicylic acid; RSH: Rectus sheath hematoma; SRH: Spontaneous retroperitoneal hematoma; OTI: Orotracheal intubation; CPAP: Continuous positive airway pressure; LMWH: Low molecular weight heparin; IU: International unit; BID: Twice daily; pRBC: Packed red blood cells; FFP: Fresh frozen plasma.

Table 2 Characteristics of the reported cases

Characteristic	Patient 7	Patient 8	Patient 9	Patient 10	Patient 11
Age in yr	86	74	65	72	74
Sex	Male	Male	Male	Male	Male
Comorbidities	AH, IHD, PE, AF, PM, CKD	AH, IHD, AF	AH	AH, asthma	AH, IHD, diabetes mellitus, AF
Chronic anticoagulant/antiplatelet use	Acenocoumarol	Acenocoumarol	No	Rivaroxaban	Rivaroxaban
Clinical presentationat admission	Fever, asthenia, loss of appetite	Fever, asthenia	Fever, asthenia	Fever, cough	Fever, asthenia, cough, dyspnea
Duration of illness before admission (days)	4	7	7	12	7
SpO2 at admission (%)	88	80	75	70	90
Time from admission to bleeding (days)	10	19	12	10	11
Type of bleed	RSH, extraperitoneal	SRH	SRH	SRH	SRH and RSH
Signs and symptoms of bleed	Abdominal, back pain	Abdominal pain, low hemoglobin	Abdominal, back pain	Abdominal pain	Low hemoglobin, abdominal pain, asthenia, swelling (right)
Hemodynamic instability	No	Yes	No	Yes	No
Maximum O2 therapy prior to bleed	7 L, mask	CPAP 85%	15 L, mask	15 L, mask	12 L, mask
Pulmonary changes	Moderate	Severe	Severe	Moderate	Severe
Length of hospitalization (days)	17	31	20	10	18
Anticoagulation (prophylactic)	No	No	No	No	No
Anticoagulation therapeutic	LMWH 6000 IU, BID; Acenocumarol	ivHEP, LMWH 6000 IU, BID	LMWH 6000 IU, BID	ivHEP	ivHEP
Antiplatelet therapy	No	ASA, clopidogrel	ASA	ASA	ASA
Steroids	Methyl-prednisolone	Methyl-prednisolone	Methyl-prednisolone	Methyl-prednisolone	Methyl-prednisolone
Bioproduct units (pRBC/FFP)	None	5/6	0/2	No	4/2
Surgery	Yes	Yes (x 2)	No	No	Yes
Outcome	Discharged	Died	Discharged	Died	Discharged

AH: Arterial hypertension; IHD: Ischemic heart disease; AF: Atrial fibrillation; CKD: Chronic kidney disease; COPD: Chronic obstructive pulmonary disease; PE: Pulmonary embolism; PM: Pace maker; ASA: Acetylsalicylic acid; RSH: Rectus sheath hematoma; SRH: Spontaneous retroperitoneal hematoma; OTI: Orotracheal intubation; CPAP: Continuous positive airway pressure; ivHEP: Intravenous heparin; LMWH: Low molecular weight heparin; IU: International unit; BID: Twice daily; pRBC: Packed red blood cells; FFP: Fresh frozen plasma.

Table 3 Inflammatory markers in the current case series

Marker	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5	Patient 6	Patient 7	Patient 8	Patient 9	Patient 10	Patient 11
At admission
Hgb in g/L	143	75	102	111	162	121	124	147	130	145	162
PLT as 109/L	197	262	179	254	325	198	354	80	178	131	103
Ly as 109/L	0.74	0.83	0.58	0.49	1.1	0.66	0.75	0.47	0.64	0.21	0.57
Cr in μmol/L	124	224	53	72	48	55	71	60	72	57	140
LDH in μ/L	330	451	154	230	502	405	241	491	638	360	760
Ferritin in ng/mL	238.8	535	1027	198.9	> 1675.5	939	1635	> 1675.5	> 1675.5	632	> 1675.5
D-dimer in μg/mL	0.68	1.1	0.30	0.98	1.57	1.07	1.55	1.95	2.03	0.61	0.77
CRP in mg/L	65.6	108	3.1	13	20.4	57.7	7.5	6.4	113.9	1.0	72.5
INR	1.0	1.1	1.07	1.07	1.02	1.0	1.1	1.09	1.01	1.1	1.33
At bleeding
Hgb in g/L	91	76	74	48	120	65	105	88	108	90	88
PLT as 109/L	271	151	206	93	200	279	245	57	222	129	149
Ly as 109/L	1.2	0.55	0.59	1.7	1.4	0.94	0.89	0.37	0.55	0.37	0.28
Cr in μmol/L	71	251	46	92	48	56	130	43	55	80	96
LDH in μ/L	335	437	155	335	441	717	311	503	521	719	405
Ferritin in ng/mL	597	243	889	166.3	720	689	971	> 1675.5	906	437	1292
D-dimer in μg/mL	5.46	1.7	0.27	2.7	2.2	1.22	2.36	1.63	2.5	0.61	0.99
CRP in mg/L	8.6	31	2.8	179.5	80.5	160	76.3	87	22.1	5.8	14.7
INR	1.0	1.0	1.05	3.5	1.04	1.0	2.5	1.1	1.06	3.6	1.51

LDH: Lactate dehydrogenase; INR: International normalized ratio; CRP: C-reactive protein; Hgb: Hemoglobin; Ly: Lymphocytes, Cr: Creatinine; PLT: Platelets.